Scott County Hospital Inc.

All Charges

Charge

Type

Setting

Price

THP Nitrofurantoin (QID) 100 mg (4 Tab) [HMC]

Facility

$46.32

Service Code	NDC 00115164301
Hospital Charge Code	3809033
Hospital Revenue Code	253
Min. Negotiated Rate	$18.53
Max. Negotiated Rate	$44.00
Rate for Payer: Aetna Commercial	$41.69
Rate for Payer: Humana Medicare Advantage	$19.45
Rate for Payer: UnitedHealthcare Commercial	$44.00
Rate for Payer: UnitedHealthcare Medicaid	$18.53
Rate for Payer: WPPA Medicare Advantage	$27.79

THP Nitrofurantoin (QID) 100 mg (4 Tab) [HMC]

Facility

$46.32

Service Code	NDC 00115164301
Hospital Charge Code	3809033
Hospital Revenue Code	253
Min. Negotiated Rate	$41.69
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$41.69
Rate for Payer: UnitedHealthcare Commercial	$44.00
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP Ondansetron ODT 4 mg (4 Tab) [HMC]

Facility

$45.44

Service Code	NDC 68462015713
Hospital Charge Code	3807885
Hospital Revenue Code	253
Min. Negotiated Rate	$18.18
Max. Negotiated Rate	$43.17
Rate for Payer: Aetna Commercial	$40.90
Rate for Payer: Humana Medicare Advantage	$19.08
Rate for Payer: UnitedHealthcare Commercial	$43.17
Rate for Payer: UnitedHealthcare Medicaid	$18.18
Rate for Payer: WPPA Medicare Advantage	$27.26

THP Ondansetron ODT 4 mg (4 Tab) [HMC]

Facility

$45.44

Service Code	NDC 68462015713
Hospital Charge Code	3807885
Hospital Revenue Code	253
Min. Negotiated Rate	$40.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$40.90
Rate for Payer: UnitedHealthcare Commercial	$43.17
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP Oseltamivir 30 mg (10 Tab) [HMC]

Facility

$192.20

Service Code	NDC 00004080285
Hospital Charge Code	3800101
Hospital Revenue Code	253
Min. Negotiated Rate	$172.98
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$172.98
Rate for Payer: UnitedHealthcare Commercial	$182.59
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP Oseltamivir 30 mg (10 Tab) [HMC]

Facility

$192.20

Service Code	NDC 00004080285
Hospital Charge Code	3800101
Hospital Revenue Code	253
Min. Negotiated Rate	$76.88
Max. Negotiated Rate	$182.59
Rate for Payer: Aetna Commercial	$172.98
Rate for Payer: Humana Medicare Advantage	$80.72
Rate for Payer: UnitedHealthcare Commercial	$182.59
Rate for Payer: UnitedHealthcare Medicaid	$76.88
Rate for Payer: WPPA Medicare Advantage	$115.32

THP Oseltamivir 45 mg (10 Tab) [HMC]

Facility

$192.21

Service Code	NDC 00004080185
Hospital Charge Code	3800100
Hospital Revenue Code	253
Min. Negotiated Rate	$76.88
Max. Negotiated Rate	$182.60
Rate for Payer: Aetna Commercial	$172.99
Rate for Payer: Humana Medicare Advantage	$80.73
Rate for Payer: UnitedHealthcare Commercial	$182.60
Rate for Payer: UnitedHealthcare Medicaid	$76.88
Rate for Payer: WPPA Medicare Advantage	$115.33

THP Oseltamivir 45 mg (10 Tab) [HMC]

Facility

$192.21

Service Code	NDC 00004080185
Hospital Charge Code	3800100
Hospital Revenue Code	253
Min. Negotiated Rate	$172.99
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$172.99
Rate for Payer: UnitedHealthcare Commercial	$182.60
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP Oseltamivir 6 mg-mL Oral Susp 60 mL [HMC]

Facility

$158.80

Service Code	NDC 00004082009
Hospital Charge Code	3800333
Hospital Revenue Code	253
Min. Negotiated Rate	$142.92
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$142.92
Rate for Payer: UnitedHealthcare Commercial	$150.86
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP Oseltamivir 6 mg-mL Oral Susp 60 mL [HMC]

Facility

$158.80

Service Code	NDC 00004082009
Hospital Charge Code	3800333
Hospital Revenue Code	253
Min. Negotiated Rate	$63.52
Max. Negotiated Rate	$150.86
Rate for Payer: Aetna Commercial	$142.92
Rate for Payer: Humana Medicare Advantage	$66.70
Rate for Payer: UnitedHealthcare Commercial	$150.86
Rate for Payer: UnitedHealthcare Medicaid	$63.52
Rate for Payer: WPPA Medicare Advantage	$95.28

THP Oseltamivir 75 mg (10 Tab) [HMC]

Facility

$207.20

Service Code	NDC 00004080085
Hospital Charge Code	3802895
Hospital Revenue Code	253
Min. Negotiated Rate	$186.48
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$186.48
Rate for Payer: UnitedHealthcare Commercial	$196.84
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP Oseltamivir 75 mg (10 Tab) [HMC]

Facility

$207.20

Service Code	NDC 00004080085
Hospital Charge Code	3802895
Hospital Revenue Code	253
Min. Negotiated Rate	$82.88
Max. Negotiated Rate	$196.84
Rate for Payer: Aetna Commercial	$186.48
Rate for Payer: Humana Medicare Advantage	$87.02
Rate for Payer: UnitedHealthcare Commercial	$196.84
Rate for Payer: UnitedHealthcare Medicaid	$82.88
Rate for Payer: WPPA Medicare Advantage	$124.32

THP Oxycodone-Acetaminophen 5 mg-325 mg (4 Tab) [HMC]

Facility

$38.85

Service Code	NDC 68084035501
Hospital Charge Code	3801434
Hospital Revenue Code	253
Min. Negotiated Rate	$15.54
Max. Negotiated Rate	$36.91
Rate for Payer: Aetna Commercial	$34.97
Rate for Payer: Humana Medicare Advantage	$16.32
Rate for Payer: UnitedHealthcare Commercial	$36.91
Rate for Payer: UnitedHealthcare Medicaid	$15.54
Rate for Payer: WPPA Medicare Advantage	$23.31

THP Oxycodone-Acetaminophen 5 mg-325 mg (4 Tab) [HMC]

Facility

$38.85

Service Code	NDC 68084035501
Hospital Charge Code	3801434
Hospital Revenue Code	253
Min. Negotiated Rate	$34.97
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$34.97
Rate for Payer: UnitedHealthcare Commercial	$36.91
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP Phenazopyridine 100 mg (4 Tab) [HMC]

Facility

$31.06

Service Code	NDC 68084029201
Hospital Charge Code	3803208
Hospital Revenue Code	253
Min. Negotiated Rate	$27.95
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$27.95
Rate for Payer: UnitedHealthcare Commercial	$29.51
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP Phenazopyridine 100 mg (4 Tab) [HMC]

Facility

$31.06

Service Code	NDC 68084029201
Hospital Charge Code	3803208
Hospital Revenue Code	253
Min. Negotiated Rate	$12.42
Max. Negotiated Rate	$29.51
Rate for Payer: Aetna Commercial	$27.95
Rate for Payer: Humana Medicare Advantage	$13.05
Rate for Payer: UnitedHealthcare Commercial	$29.51
Rate for Payer: UnitedHealthcare Medicaid	$12.42
Rate for Payer: WPPA Medicare Advantage	$18.64

THP Potassium Chloride ER 10mEq (4 Tab) [HMC]

Facility

$32.20

Service Code	NDC 60687046601
Hospital Charge Code	3802044
Hospital Revenue Code	253
Min. Negotiated Rate	$28.98
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$28.98
Rate for Payer: UnitedHealthcare Commercial	$30.59
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP Potassium Chloride ER 10mEq (4 Tab) [HMC]

Facility

$32.20

Service Code	NDC 60687046601
Hospital Charge Code	3802044
Hospital Revenue Code	253
Min. Negotiated Rate	$12.88
Max. Negotiated Rate	$30.59
Rate for Payer: Aetna Commercial	$28.98
Rate for Payer: Humana Medicare Advantage	$13.52
Rate for Payer: UnitedHealthcare Commercial	$30.59
Rate for Payer: UnitedHealthcare Medicaid	$12.88
Rate for Payer: WPPA Medicare Advantage	$19.32

THP PrednisoLONE 15mg/5mL Oral Suspension (60mL) [HMC]

Facility

$62.47

Service Code	NDC 00121075908
Hospital Charge Code	3803471
Hospital Revenue Code	253
Min. Negotiated Rate	$24.99
Max. Negotiated Rate	$59.35
Rate for Payer: Aetna Commercial	$56.22
Rate for Payer: Humana Medicare Advantage	$26.24
Rate for Payer: UnitedHealthcare Commercial	$59.35
Rate for Payer: UnitedHealthcare Medicaid	$24.99
Rate for Payer: WPPA Medicare Advantage	$37.48

THP PrednisoLONE 15mg/5mL Oral Suspension (60mL) [HMC]

Facility

$62.47

Service Code	NDC 00121075908
Hospital Charge Code	3803471
Hospital Revenue Code	253
Min. Negotiated Rate	$56.22
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$56.22
Rate for Payer: UnitedHealthcare Commercial	$59.35
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP Prednisone 20 mg (4 Tab) [HMC]

Facility

$28.39

Service Code	NDC 00054001820
Hospital Charge Code	3806680
Hospital Revenue Code	253
Min. Negotiated Rate	$25.55
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$25.55
Rate for Payer: UnitedHealthcare Commercial	$26.97
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP Prednisone 20 mg (4 Tab) [HMC]

Facility

$28.39

Service Code	NDC 00054001820
Hospital Charge Code	3806680
Hospital Revenue Code	253
Min. Negotiated Rate	$11.36
Max. Negotiated Rate	$26.97
Rate for Payer: Aetna Commercial	$25.55
Rate for Payer: Humana Medicare Advantage	$11.92
Rate for Payer: UnitedHealthcare Commercial	$26.97
Rate for Payer: UnitedHealthcare Medicaid	$11.36
Rate for Payer: WPPA Medicare Advantage	$17.03

THP Prednisone 5 mg (4 Tab) [HMC]

Facility

$27.97

Service Code	NDC 00054872425
Hospital Charge Code	3803357
Hospital Revenue Code	253
Min. Negotiated Rate	$11.19
Max. Negotiated Rate	$26.57
Rate for Payer: Aetna Commercial	$25.17
Rate for Payer: Humana Medicare Advantage	$11.75
Rate for Payer: UnitedHealthcare Commercial	$26.57
Rate for Payer: UnitedHealthcare Medicaid	$11.19
Rate for Payer: WPPA Medicare Advantage	$16.78

THP Prednisone 5 mg (4 Tab) [HMC]

Facility

$27.97

Service Code	NDC 00054872425
Hospital Charge Code	3803357
Hospital Revenue Code	253
Min. Negotiated Rate	$25.17
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$25.17
Rate for Payer: UnitedHealthcare Commercial	$26.57
Rate for Payer: WPPA Medicare Advantage	$1,200.00

THP Promethazine 12.5 mg (4 Tab) [HMC]

Facility

$31.75

Service Code	NDC 68084015401
Hospital Charge Code	3800168
Hospital Revenue Code	253
Min. Negotiated Rate	$12.70
Max. Negotiated Rate	$30.16
Rate for Payer: Aetna Commercial	$28.57
Rate for Payer: Humana Medicare Advantage	$13.34
Rate for Payer: UnitedHealthcare Commercial	$30.16
Rate for Payer: UnitedHealthcare Medicaid	$12.70
Rate for Payer: WPPA Medicare Advantage	$19.05

Know your out-of-pocket cost for care.

All Charges